It's a city of 79,000 people. It's one of the poorest cities in the country -- first, second or third poorest city depending on how you measure it. It's one of the most dangerous cities in the country. It's had three of its last six mayors indicted and convicted of corruption. It's just recently laid off half its police department. [It's an] incredibly challenged place. It's been taken over by state government -- the city government, school district, police department -- in various stages, at various points. So it's a very challenged small city.

How does that get reflected in health care? Is that any different?

We have two hospitals, three emergency rooms; we've got about 12 primary care offices in the city of Camden. ... People really struggle to get health care in the city. There are long waits in the emergency room. People call for an appointment, and first available appointments can be days, weeks or months away.

“It pretty quickly became clear that there were hot spots of everything. There were hot spots by disease, hot spots by patient... There were hot spots by ZIP code and by neighborhood. … You could begin to take the data and tell stories with the data. And that's an incredibly powerful tool for making change.”

They struggle with environmental contamination both inside their house and outside. We have a lot of air pollution in the city of Camden, high rates of asthma. There are very old homes here, so that makes health conditions worse.

People can't exercise [when] they're afraid to walk on the streets. It's a very violent place, so it's hard to get exercise here. People are afraid to let their kids out of the house. The schools are falling apart, so it's just a really tough place. The overwhelming sense I get from practicing medicine here, and living here as well, is that it's an unbelievably stressful place.

So you came to practice here. Why?

I finished residency in Seattle, and I grew up around here and wanted to come back to New Jersey, and I really wanted to practice in an underserved community where I could speak Spanish. Camden is a great place to be if that’s what you want to do. I wanted to see kids, adults, delivery babies, and wanted to take care of families, and there are lots of families here that need good care. ...

... Was it really that different from what you were seeing when you were training in Seattle or in medical school in New Jersey, or was it a different set of illnesses and a different set of conditions entirely?

No, it's all the same conditions. I worked in a federally [subsidized] health center in Seattle and took care of homeless people and undocumented immigrants for three years as part of my training, so I was pretty deeply steeped in how to care for complex problems.

And there are so many ways that illness manifests. It manifests as diabetes and hypertension and headaches and back pain and knee pain, but the common denominator to all that is stress. When people feel like their life is out of balance, when they feel like their life is out control, that they can't change their life circumstance, that's an overwhelming feeling.

So that's what I saw pretty quickly in my office, is that all of the broken school district, the broken police department, broken city government, all of that added up to an enormous amount of stress, and that it was impacting people's health and wellness and their sense of themselves and the sense of their family. …

[What changed your whole perspective on how you did things?]

It was a gradual process. Living in the city, you hear gunshots ring out all the time. It feels very unsafe in the city, and you're constantly sort of looking over your back and just thinking about where you are at all times. And that's a low level of stress that you live with every day, and it has an impact on you. Working in my office, we got broken into pretty frequently. …

Patients come into your office who have been beaten up, who have been assaulted, who have been held up at gunpoint, who are rolling around in wheelchairs because they've been shot, and they're around my age or younger than I am.

And it's just a sense of overwhelming chaos, and you think, there has to be a fix to this. I mean, someone has to be figuring this out. There has to be a better way of doing this.

There was a lot of literature around violence being a public health... So I really began to dive into just reading about cities and urban history and economics and policing strategies and what's gone on in New York, and realizing that people have made a lot of progress.

The neoconservative literature on community policing is very interesting, because it essentially says that poverty doesn't have to equate to crime and violence; that it's possible to have a safer community, a healthier community without fixing poverty. And over and over I think people have been paralyzed thinking that until we fix all of poverty there's no hope for education, for making a place safer and healthier. And the neoconservative literature says that [is] wrong, that you can actually improve these public systems and make health care work better for people and help them get healthier. You can make education work; you can make policing work.

... The final culmination of this was, I was working in my house one evening and heard gunshots and then got a call from a neighbor, and the neighbor said: "There's someone [who's] been shot in the neighborhood. You should come down and see what you can do." So I had stuff in my house, a pocket mask and a stethoscope, and went running down the street.

It was in the evening; it was dark. There were lots of flashing lights; the police had gotten there already. There were probably about 12 officers standing around, and there was a station wagon near a street lamp, and there [were] people milling around.

So I walked up and asked the police: "I'm a physician. Where is the victim?" And they all sort of turned around and said, "He's over there." And he was lying down. He had gotten out of the car probably and sort of fallen, and he was laying on his side, facing the back tire. And [I] ran over, and he had pulse. He wasn't breathing. [I] rolled him over on his back, opened his airway [and] started rescue breathing. Eventually his pulse stopped. [I] started compressions. Eventually a Rutgers police officer came over, and I slowly heard an ambulance pulling up and people coming over. We ended up getting him in the ambulance. It was dark; he was in a shadow. It just wasn't clear what was going on. You just do whatever you need to do in the situation. And I was furious. I stood up and started screaming at the cop, "Why didn't you guys do anything?"

You were angry that they hadn't been even tending to the victim?

Yeah, that they hadn't done anything. And I said, "Why didn't you guys help him?" And the police officer said, "We didn't want to dislodge the bullet." It was just a complete blow-off, and I was just so furious.

I'd had patients come in all the time and tell me crazy stories about the police department and what goes on in the city. You just don't want to believe that social disorder has broken down to that extent. And I thought this is the most dangerous city in the country; there are people being shot all over the city and being hurt; every night there's a couple of these incidents. I couldn't imagine how we could have reached the point in our society in this city where you would just leave a victim lying there in their own blood.

... And it turned out that -- I lived close to Rutgers -- he was a Rutgers student, and he was a senior.

The victim?

Victim. He had grown up in the city. He had worked hard. He had succeeded. He'd come from a very poor family, and he was close to graduating. He already had a job lined up at a bank, and he was one of the wonder kids that make it out of urban communities, and he was just about to make it out. He still had friends that were part of the drug trade in the city, and they were trying to get one of his friends and kind of got him instead.

And you sort of snapped at that point?

I was furious. I was so angry and didn't know what to do. I just didn't have even a framework for what do you do in this circumstance. We had some public meetings and really started reading and trying to figure out, get to the bottom of this.

… We ended up organizing a march [with] all of his friends from Rutgers. We started at Rutgers and marched to the police department, and we [brought] CPR manuals and CPR equipment and first aid equipment. They wouldn't come out and talk to us, so we walked one at a time into the police department and left it there in their lobby. I think [we] made a very strong statement that they were an unaccountable system that had behaved very poorly and needed to change how they operate.

The striking thing is that they put you on the citizen reform commission for the police department. Did you want to be the citizen member of the police reform commission?

There were two of us, and I did. I thought it would be a chance to really start fixing some of this stuff.

… It is incredibly revealing to be on the commission, because the police department had been in takeover for many years, and I'm sitting with the county leadership from the prosecutor's office, leadership from the state police, from the state attorney general, and they're talking very bluntly [behind] closed doors about how frustrated they are to fix it, and how for many, many years they been working to fix it.

They brought in really amazing outside consultants to come in to help to figure all this out. And I got a chance to meet many of the disciples from New York, from [former NYPD Chief of Police William J.] Bratton's department, and people who had helped turn New York around and rethink policing across the country. It was an amazing experience to talk to people who had really figured this out, who understood the connection between poor service delivery on the end of a system and how you build a system and what the structure of the system looks like.

So what do you think you do if you are trying to tackle crime in a city like Camden and you're getting lessons from elsewhere? What do you zero in on as a way to get a handle on it?

You can't fix a hard problem unless you have a way of counting the hard problem. It became very clear that the city had no ability to track statistics, to map things, and that their system was really missing a lot of data, I thought.

It was pretty clear to me that a lot of patients weren't reporting crime, that I would have people come in and they'd been beat up and I was taking their stitches out, and they said: "Why should I report the crime to the police department? No one will follow up on it."

The clearance rate for crimes, meaning the solve rate for crimes, was only about 18 percent in the city. That's for severe crimes. So I really felt like the first thing to do in solving a problem is to count it. ...

And is that [what] they'd done in other cities?

Yeah. My understanding is the first thing that they did in New York is really put together something called CompStat, which was a way of recording crime data and then mapping it so that you knew at the block level, at the neighborhood level, what the crime rate was.

You could see where the hot spots for crime were?

Where the hot spots are, exactly.

And then what would they do?

They created a management structure to support that. Fundamentally, the question is, if a system is failing or if crime is high, who's the accountable manager? And Bratton decided that the precinct captains would be the accountable managers, and he brought them every week to a room, and they put the maps for their precinct up, and he asked: "What are you doing about it? What's your plan to fix the problem?" …

Did the police have maps? Were they mapping just like everywhere else?

No, they weren't. No. The police really didn't have good data, and they had bought systems that they didn't know how to get to work. They had paid a lot of money for the systems, and they kept buying new systems, and they still struggled to really use maps in a productive way.

So we decided to go directly to the hospitals, and I went to the hospital that I worked for and submitted a proposal to collect patient-level information for everyone who had had an accident or injury, so this included people who had been shot, people who had been assaulted or fallen down the stairs. We got the data and began -- it was a student project. I was working with a student, and we mapped it, graphed it, charted it, and it was just an unbelievable data set. …

It pretty quickly became clear that there were hot spots of everything. There were hot spots by disease, hot spots by patient; there were certain patients who had been [admitted] over and over and over. There were hot spots by ZIP code and by neighborhood. …

And because I knew the city so well, you could begin to take the data and tell stories with the data. And that's an incredibly powerful tool for making change.

So next thing you know, you've got the maps of the city for crime from the hospitals, and you start seeing patterns in the health of the population as well. What were you starting to see?

Yeah. At some point I gave up on thinking that I could impact the police department… [I] eventually just said, "I'm going to go back to being a doctor."

But then you had on your computer all of this --

All these great maps and graphs and charts, and so we decided to widen the database out and went back and decided that there are such wonderful patterns to all of the accidents and injuries that there's probably wonderful patterns in other things as well.

So we went back and asked each hospital for all their claims data for a full-year period, and did the same thing with that data and began to find buildings in the city that were hot-spot buildings, where there were a lot of elderly and disabled people living in the building that were generating enormous amounts of costs, going to the emergency room and hospital over and over; that there were specific patients in the city that were going over and over to the hospital.

Here was the leap that really struck me: You went from mapping one kind of consequence, assault and crimes, to really mapping the costs of the city and how they unfolded, and you found they were incredibly concentrated.

Very concentrated.

How concentrated is it?

So the two most expensive buildings in the city are both beautiful buildings that have good people running the buildings. One building had $15 million in payments to the three hospitals for emergency room and hospital care, for the people living in that building. It's about 350 people. The other building had about $12 million in payments to the three hospitals for about 600 people living in the building. That's over a five-and-a-half-year period. …

What percentage of the city accounts for, say, half or two-thirds of the costs?

One percent of the city residents are responsible for about 30 percent of the hospital and emergency room costs. So it's very, very concentrated. In a one-year period, half the population uses an ER hospital, which is higher than the national rate.

The leading reason to come to an emergency room in Camden over a five-year period is head colds. There were 12,000 visits for head colds. Number two is ear infection. Number three is sore throat. Number four is asthma. Number [five] is stomach virus. I mean, it's all primary care problems. Even if you take out the uninsured patients from the data and just looking at people with insurance, it's the same list.

You said 1 percent accounts for 30 percent of the costs. Five percent accounts for 60 percent of the costs. Is that unique to Camden?

What we've learned and what I've learned over time is that every group that you look at in health care has similar patterns. If you look at commercially insured patients, if you look at Medicare patients, if you look in a specific company, that it's all from the same pattern. It's about 1 percent of the patients [that] are costing about 30 percent of the health care resources.

So that makes a certain amount of sense: The sick people cost the most.

Right.

… I would have guessed that they're very expensive because they are getting expensive and great care. You didn't think that was the case?

So the nice thing about being a practicing physician and getting a chance to look at this kind of data -- which never happens, by the way; doctors never get a chance to look at data; it's really hard to get this kind of data -- is that it's a small city, and my patients from my practice that I've taken care of for years are in the data.

So you sit and begin to look through the data, and I'm looking at my patients who are in the data and realizing I had no idea how much health care cost. I had no idea how expensive it was. It was just shocking. …

Did you think that when you looked at the most expensive patients in your numbers that it looked like what they were getting was great care?

It was really obvious from the data that the most expensive people were getting terrible care. They were getting disorganized, fragmented and uncoordinated care.

And I knew them, so I knew what kind of care they were getting. And it was a very common scenario to have an extremely complex patient discharged from the hospital, show up in my office, and I'd walk in the exam room, and say: "Mrs. Rodriguez, I haven't seen you in three months. Where have you been?" "Well, I've been in the ICU for a month and a half. I've been in the hospital for another couple of weeks and just got out a couple of days ago." And I said, "Well, what happened?" And she'd say: "Well, I'm not really sure. Lot of doctors came in the room. They never really explained anything to me. No one translated, and I'm not really sure. But I got this scar, and I've got this whole bag of medicine, and I've got a one-page carbon-copy discharge sheet, and all the meds have been changed, and [it] doesn't really say anything."

So you'd call the hospital, and the hospital had not done the discharge summary yet. They hadn't dictated anything. They couldn't find the chart. You couldn't figure out who had actually taken care of the patient.

So now you've got this incredibly sick person who's got new complaints. They're complaining of chest pain today and shortness of breath. You really have no idea what happened to them in the hospital. They cost $20,000 while they were in the hospital, so the public paid $20,000 for their health care, and now I'm trying to figure out how to make sure they don't go back to the hospital, and I can't figure out what the hospital did to them.

So you've got a group of people who are the most expensive people in Camden. Some of them are in your own practice. And you thought they were not getting great care. How did you think you could tackle that? ...

One approach to reducing costs is what they call consumer-directed health care. That's giving patients more skin in the game. That means upping your deductible, your co-pay, so that you're penalized for using more services.

The problem is, the most expensive people are lying in ICU beds, and you're hardly empowered to turn your card over and check your deductible or to open up Consumer Reports and find out how expensive your care is.

So we talk about consumer-directed health care, but it only works essentially for a healthy person who wants an MRI. And that's really at the margins. That's a small part of the cost drivers. The bulk of the cost drivers are the most sick people who are least able to be consumers within the system. So that model of saving money doesn't really work.

… What's your approach then?

What I knew from my office is that I'm paid to go from room to room to room as fast as I can, and the faster I go from room to room to room, the more money I make. When I slow down and I get involved in a complex case, I may as well hand money over the patient. I lose money. So that's a terrible model of care.

…You can't do good care in 10 minutes. It just doesn't work. If it's a head cold, that's fine, but if it's a complex diabetic who's just left the hospital and has got a healing diabetic foot ulcer, it's going to take some time to explain to the patient what's going on and to straighten out their medications and talk to the family members, and I knew that when I spent more time with people that they began to understand their care, and they felt empowered, and they were less likely to go back.

For that 1,000 people who are 30 percent of the costs, how many doctors could they have had just on the bills that they were paying?

A good way of thinking of that is in one of these buildings that we talked about. So for the amount of money that we're spending in one of these hot-spot buildings that are filled with elderly and disabled people, $12 million over five years is enough to put a nurse practitioner on every floor of the building.

If you look at the total spent on the most frequent utilizers in the city, it's about $10 million a year. That would be enough to hire 50 of me, which is more than the total number of primary care providers in the city.

Essentially what's happened over time is that we built a specialty care and hospital system on steroids, and if you pay more for something, you're going to get more of it, and you pay less for something, you're going to get less of it. We have shrunk and shriveled our primary care base.

And the impact for patients in Camden is that if I want a patient to get evaluated for a kidney transplant, I can get them in this week. If I want a patient to be able to get in for a basic appointment to control their diabetes and adjust their blood pressure medicine, they could wait for weeks or months. And that just doesn't make sense. We're being foolish in how we're deploying resources in our health care system.

[What does] American health care need to focus on and pay for?

American health care doesn't do a good job taking care of sick people. The way we built our system is really a system that's very hard to access. It works well for the average patient, but if [you] are blind, if you're deaf, if you're disabled, if you're in a wheelchair, if you don't speak the language, if you're developmentally delayed, if you have a complex mix of illnesses with many providers involved, the whole system starts to break down. Patients often get overwhelmed. They are going from doctor to doctor, specialist to specialist. They're getting conflicting recommendations. The doctors aren't talking to one another, and they get confused, and they get overwhelmed. They get lots of medications added to their regimen. ...

And those are the people that were in your top 1 percent most expensive people?

Those are the people that are in our database, and those are the people that live in every community all over the country. …The story that I'm telling [is], you don't really understand until you've been one of those families.

... Tell me about the first patient that you tried to understand.

…This was a 45-year-old patient with an acute attack of gallbladder disease who had a history of heart failure, poorly controlled diabetes, severe obesity. ... He was morbidly obese. He was probably about 600 pounds. So this was a very complex patient when he came into the hospital and, within a day of being in the hospital, ended up in the intensive care unit with severe infection, and was there for about a month and a half and close to dying.

Was that that pattern of how it had been for him, or is this just a particularly terrible and very expensive episode at the top of the chart?

He'd been in the hospital in the last six months two other times, in nearby hospitals, and each time for a month for heart failure episodes, and also other problems with his gallbladder. So he was a really sick guy with a lot of complex problems, and he was scared. He understood that he had almost died in the intensive care unit.

Was he going to be a high-cost patient again in the future? Or he sounds to me like a guy who got really sick, had his expense in the past, and now would gradually get better and of course would be lower-cost over time.

He would highly likely continue to be a high-cost patient. Heart failure patients are one of the most complex and expensive patients to care for. It's a chronic disease. You don't get better. It gets worse and worse over time. So, you know, he was highly likely to continue ending up in the hospital over and over.

... Sounds kind of hopeless to me.

So I was very worried. Here we had gotten funding for this project. We were going to begin meeting and addressing the needs of these patients, and our original model was just to hire a nurse. And I quickly realized that, based on this patient, that these are patients that weren't getting access to care; that just giving them an appointment wasn't going to mean that they were going to get follow-up care; that we were going to actually have to deliver their follow-up care.

This guy sounds like he was getting good care.

He was so obese that he couldn't move around, and getting him from doctor to doctor, appointment to appointment and follow-up appointments is very challenging. He was homeless, living in a motel room, and was poor, didn't have access to transportation, so he had a lot of barriers to getting access to care. So he would be discharged back to the motel, and in fact was discharged back to the motel from this hospital visit as well.

And how is that bad care?

He was getting bad care because fundamentally the question is, are we going to be a proactive delivery system that brings good care to patients, or are we going to be a passive delivery system and wait for patients to come to us? And sick people are overwhelmed by their illnesses sometimes. … It's much cheaper to bring good care to people than to wait for them to figure out how to access care. ...

What was the way that you then tried to tackle the problem?

[I] really felt like we needed to go out and see these patients and bring care to them and not wait for them to come to us. So --

Would that keep them out of emergency rooms and ICUs?

That's what we thought. And it turned out it's true. That is the answer. So we hired a nurse practitioner, community health worker and social worker. And the four of us as a team began to care for these patients. We asked for referrals directly from the hospitals of their complex, high-cost patients. We'd often meet the patient while they were still in the hospital and then follow them out, so they got to know us in the hospital, and then when we knocked on the door the next day, they were excited to see us, and they felt like finally someone cared about them.

If you didn't do that, how often would they end up back in the hospital?

Nationally, the statistics for older patients who have Medicare -- so these are people over 65 -- is that 20 to 25 percent of Medicare patients end up back in the hospital within the first 30 days.

And how often do you think that's the case for these really high-cost patients that you were concentrating on?

I think that half of them end up back in the hospital within the first 30 days.

And you could change that?

We thought we could change that by bringing care to them. We've lost the art of the home visit. There's something very powerful about going into someone's home, building a relationship, sitting down with them, getting to know them, getting to know their family members. And there's something very empowering to patients when you come to them. It can be frightening to be in a doctor's office, and it can be frightening to have a doctor in a white coat walk into the room. It can be alienating to patients. And it sends a really powerful message of how much you care about them when you come to their house. And you also realize the circumstances they're living in.

As physicians and health care providers we often blame patients when they don't follow our directions. The number of times I've had clinicians and nurses and doctors tell me, "Well, if the patient would just follow my directions, if they would just take the pill that I gave them, if they would just follow the diet I gave them, then they'd stop being sick; they'd stop coming back to the hospital" -- and it's not that simple. ...

It almost sounds like a science of connecting the dots in why people become unhealthy.

Absolutely. It's like detective work. And you just keep pulling one lid after another, and you just realize how complex health care is and how complex illness is, but that we can do better, and that it is solvable. …

You were talking earlier about that [the] really high-cost patient is the most frustrating patient for doctors. I see some of these folks who -- they don't follow what you ask them to do, and what you're saying is you can connect the dots to change their situation?

You can't completely alter people's life circumstances. We're not going to cure poverty in my lifetime, I don't think. So the question is, how can you take the current situation that a patient is in and improve it enough to make them a little bit healthier, and lower their unnecessary ER and hospital use, and make them have a more productive interaction with the health care system?

... How much does it save walking in the door and actually finding a solution for that very micro problem? … One emergency room visit can be $1,000 to $3,000. One night in the hospital could be $2,000 or $3,000 or $4,000. …

... What's the cost of your team?

Two hundred twenty-five thousand dollars in a year. The most expensive patient that our team is caring for had $600,000 in hospital bills paid out over the last five years, and 43 of the patients we're caring for had $3 million in payments to the hospitals over the last five years. So the care right now for these folks is really expensive. So it's much cheaper to bring care to them and deliver better care than it is to have them keep going to the emergency room and hospital over and over.

How much has your team been able to lower the costs for this really expensive group of patients?

So we've seen some preliminary results of 40 to 50 percent reductions in visits and costs. And we're now --

Forty to 50 percent reduction in costs?

In costs and visits. And we're beginning to dive deeper into the data and have partnered with a research team to really pull this data apart and figure it out, and understand in more detail what are the cost drivers and how well is the project working.

Yeah, I'm sure trying to calculate exactly what the savings are is pretty tough. But your $225,000 team is saving millions for sure?

We think so, yeah. We think that we're pointing the way with this team to better care at lower costs by bringing care to patients in the community.

And this is not a new idea, by the way. There are wonderful projects around the country over the years that have done similar things. There's a program called PACE, Program for All-Inclusive Care [for] the Elderly, that is a similar, very proactive, very well-developed model of bringing care to frail, elderly patients that's demonstrated savings. There's another model for severely mentally ill patients called Assertive Community Treatment Team [ACTT] that brings better care right to the community for patients and saves money. So this isn't a new idea; we're just applying it in a different environment. …

So your $225,000 team that can save millions, it exists in other cities around the country in a similar way. Why haven't they taken off?

There are no billing codes for this. There's no way currently to bill insurance or to bill Medicaid or Medicare for the kind of care that a team like this delivers. And there have been similar projects that have gone away. There were sites in California that couldn't continue their funding and had to fold. So this isn't an entirely new idea. Other people have tried this, but it's just very hard to get sustainable funding for this kind of work.

So now you're actually trying to harness health reform to change the entire way things are paid for in Camden, so that you can build teams like this?

Right. We've worked closely with the New Jersey Chamber of Commerce, the New Jersey Hospital Association, Citizen Action, nursing groups, provider groups to put together legislation in New Jersey that is close to passing that would essentially create a sustainable funding model for this kind of work. It says we don't want any up-front money, but if we generate savings that the state will share a portion of those savings back with us. So we think that this is, right now, the way to go forward in this kind of work, which is share some of the savings we're generating back with the project so that we can grow this kind of work.

I thought President Obama's health reform was supposed to do that. Is it not going to do that for you?

Oh, no. I think health reform is an incredible opportunity for agents of change all over the country to begin building projects like this and fixing health care from the bottom up. … The problem is that the pace of cost increase is going up so quickly that I'm not sure that the pace of innovation is going to be fast enough.

… Your small investment of time up front is leading people to use the emergency room less, not show up in the hospitals. You're trying to get the hospitals to come along with you on this. Why is that going to work at all? You're taking away business that is their financial lifeblood. They want to keep the hospitals full, keep the emergency room going.

So the one part of the market share that all the hospitals are gladly willing to give up is complex homeless people who might have substance abuse histories or mental illness. So we went to a group of patients that everyone had given up on and that no one wants more of. …

As this kind of an experiment works, though, you're talking about dropping the number of hospital visits as a whole.

Yes.

You're talking about removing people from emergency rooms.

Yes.

They could have to shut down floors and beds.

Yes, yes.

They're not going to be with you on this, are they?

This kind of work is a game changer, and this is a Blockbuster Video moment for America's hospitals, and --

What do you mean by a Blockbuster Video moment?

So along comes Netflix, and Blockbuster Video has closed down stores all over the country, and there had to have been a moment somewhere when a young executive walked in and said, "Hey, they're starting to rent videos online," and Blockbuster said: "No, people like coming to the video store. We're not going to make any change. We've got a good business model, and it's working." So disruptive change comes along, and it can take a model and turn it on its head.

And I think better care for sick people is disruptive change. And if we scale this model up that we don't need as many hospital beds, we don't need as many specialists, that's a really big problem. We have an enormous political problem, which is if we want to balance the federal budget, if states are going to balance their budgets, if businesses aren't going to go bankrupt or drop health care coverage from the increase in costs, then we're going to have to deliver better care to sick people. And the impact of that is going to be big change. It's going to be fewer hospital beds, fewer hospitals and fewer specialists, and that's going to be a pretty big change. We have inflated a capacity bubble in our country to do expensive, high-tech, hospital-based care, and it's a little like the bubble we inflated for housing. At some point you inflate a bubble past its true need in society, and when we pop that bubble, it's going to be a very painful process.

… One criticism that I've heard about the approach that you're taking [is that you're] bringing people into people's homes, looking in their refrigerator, checking what they're eating. Isn't this the nanny state being inserted right into people's homes in order to control health care costs?

What we have found is that patients are really excited about this model of care. We are not pushing ourselves on patients; we're asking patients whether they'd like to be part of the project. And by and large, almost all of the patients we've ever met have been incredibly excited. They feel like the health care system ignores them. …

They're getting a medical Sherpa coming right to their home. ... It's like getting an intensive care doctor who actually comes to your home.

Exactly. That's right. ... We're bringing better care to them so they feel like they're being taken care of. Someone is paying attention to them finally.

So do they experience it as a nanny state? ... They don't ever push back and say, "Stay out of my fridge"?

No. It really has not been the response. Our biggest problem is getting patients transitioned back off the team. Our single biggest problem right now is that the health care system is so broken that we, when we want to -- our hope is to take care of someone for three to six months, provide their primary care, get them kind of tuned up and then pass them back to the system. And there is no one to catch them. The primary care is so broken and underfunded and undercapitalized, there's no one to catch them. There's no one to pay attention to them, you know? There are doctors running from room to room to room in 10-minute encounters who can't pay attention to these people. So the biggest challenge is that we tune them up, and we have no place to send them, which is sort of sad.

So with Derek Williams, severe asthma, bouncing in and out of the hospital, what is it that you're trying to make sure your team does?

The core solution to all this is teamwork, and it's case conferencing, and it's meeting regularly and talking about the problem with a team of professionals who bring different perspectives. If you had a problem in your business, you would bring a group together, and you'd talk through it and try and solve it. And we don't do that in health care.

Who's his team?

His team is a nurse practitioner, community health worker and a social worker. It's our outreach team, and every week they do internal case conferences, and they run all the cases, and they talk about what the barriers to care are, the challenges, and brainstorm solutions. And every month the whole city comes together -- front-line providers, social workers -- and we do anonymous case discussions at the city level. And what we do is try and pull out common barriers and themes that we're seeing over and over among the patients, and then elevate that up to my board and think in an organizational level, how can we be solving systematically the barriers to care?

So you're changing medicine from being individual, physician-focused to specialist is the king to a team of people having to work together, and the team is the king. Is that the concept here?

That's exactly right. So this is team care, and it's using story by story by story to pull out narratives that indicate where the system is failing, and then systematically working through those problems at a patient level, but then putting those stories together at the city level and trying to solve those problems at the city level.

So if Derek has trouble where his asthma is being driven by the conditions of his home, what are you trying to get your team to do?

We've reached out to partners in the city and we've asked them to help us, so [we] reached out to an organization that can help to do rehabilitation in homes and partnered with them and asked them to help us -- you know, what can we do for rehabilitation in his roof and fix the leaks and see if we can make a difference? And ultimately we think that would dramatically reduce his asthma exacerbations.

His family probably lives on about $1,000 a month, so they're not really capable -- they're barely able to make ends meet.

So it's poverty again?

Yes. It's poverty.

You said earlier we're not going to fix the poverty.

Right.

So you're stepping in to fix a corner of it that is causing his health problems?

Yes.

So how do you bring a team to focus? I'm not going to fix the poverty. What are you going to focus on?

Change is really lots of little baby steps that add up to better and better care, so the smallest things can make a difference. If a patient is not able to get their refills, it can be a matter of getting a pharmacy that delivers. If they can't get across town to a doctor, it might be finding a doctor that's closer to their house. If they don't understand what time of the day to take the medicine, it could be a matter of doing a lot of education and writing it out or drawing pictures if they can't read. It can be a matter of pulling on family support or pulling on church support. There are lots and lots and lots of ways to solve problems, and it's a matter of pulling a team of people with different perspectives to work together to solve those problems.

Yesterday Cathy, the nurse practitioner, discovered that Derek had run out of refills on his medications and wasn't allowed to refill them. How do you as a team try to tackle that kind of problem?

So a lot of the time it's advocacy. You end up calling the insurance company or working with the pharmacy to kind of work through those things and get permission to be able to get refills. I think he had lost his machine, his nebulizer machine for his asthma, and the pharmacy wouldn't give him another one because the insurance company wouldn't approve it. So it's a matter of getting on the phone and explaining who he is and what's going on, and helping him get another nebulizer. And he was going to the emergency room over and over, partly because he didn't have a nebulizer in the house to be able to get his treatment and didn't have refills on his medicine. Patients can be really overwhelmed by their problems and not be able to advocate for themselves, and [they may] need some help to be able to navigate the very complex approval processes that we've created.

… So Derek, you've sent teams out to visit him at home, and then you're bringing them back to do what?

Mm-hmm. So the irony with Derek is that for a small portion of the cost of the hospital bills he's generating, we could buy him a brand-new house and put it in Camden. Penny-wise and pound-foolish.

The way we built our public systems is they're in silos. There's a bucket of money here and a bucket of money here. So there might be housing subsidy here; there might be health care subsidy here; there might be education money; there might be prison money. What we don't realize is that if you push down over here, it pops up over here. So you know by not providing people with decent housing, they're going to overrun the hospital.

You're having a meeting at the end of this month with other folks around the city. What is that going to possibly do for Derek?

It's going to widen our team. [It shows] that it takes a community to begin to address these issues. …

I'll give you an example. Most housing agencies don't put a priority on patients who are going to the emergency room and hospital too much, so we have federally funded housing agencies that have slots, and it's just sort of a waiting list, a random waiting list to get into those slots, whereas what we should be doing is prioritizing people like Derek and his family to be able to get into those slots, or patients that are overutilizing the emergency room and hospital. The message that we've been taking to Trenton and policy-makers is if you only have so many resources, why not invest money here to reduce costs over here, and do it in a measurable way?